Sd Form 819 – Fill Out and Use This PDF

1.

EMPLOYEE NAME (Last, First, Middle Initial)

2. ONBOARD DATE (YYYYMMDD)

3.

EMERGENCY CONTACT (Optional)

a. NAME (Last, First, Middle Initial)

b. TELEPHONE (Include area code)

c. CELL PHONE

4.

HOME ADDRESS (Street, Apartment Number, City, State and ZIP Code)

5. HOME TELEPHONE NUMBER

(Include area code)

6.

ORGANIZATION/DIRECTORATE

7. DIVISION/BRANCH

8.

SUPERVISOR NAME (Last, First, Middle Initial)

9. DUTY ROOM

10. TELEPHONE NUMBER

11. POSITION SENSITIVITY (X one)

1.

AGENCY NAME

2.

AGENCY ADDRESS

3. AGENCY TELEPHONE NUMBER (Commercial or DSN)

4.

EXPIRATION DATE OF CONSULTANCY/IPA (YYYYMMDD)

SECTION 4 - COMPLETE IF MILITARY PERSONNEL

1.

SERVICE

2.

RANK

3.

LEVEL (X one)

4. STATUS (X one)

OFFICER

ENLISTED

ACTIVE

RESERVE

5.

MILITARY OCCUPATION CODE

6.

DUTY TITLE

2. START DATE (YYYYMMDD)

3. END DATE (YYYYMMDD)

4. DUTY TITLE

5. EMPLOYMENT TYPE/CATEGORY (X one)

SD FORM 819, FEB 2009

Page 1 of 3 Pages

1. COMPANY NAME

2. COMPANY ADDRESS (Street, Suite No., City, State and ZIP Code)

3. COMPANY TELEPHONE NUMBER (Include area code)

4. EXPIRATION DATE OF CONTRACT (YYYYMMDD)

SECTION 7 - IN-PROCESSING REQUIREMENTS

Organizations should enter specific location/room numbers as appropriate.

Enter "N/A" under "date completed" for inapplicable action items.

ACTION ITEM

INITIAL/DATE COMPLETED

1. COMPONENT (OSD/WHS Component Administrative Officer)

Room No.:

a. Personnel Locator Form

b. Update Organizational Telephone Directory

c. Parking Information (Pentagon or PMI)

d. NCR Mass Transit Subsidy Program

e. Government Travel Credit Card

f.

Government Travel Card Account Transfer Form

g. DD Form 2918 or SD Form 37 for financial disclosure filing determination

h. Telephone set up and password

i. Notification to Defense Travel System (DTS) Manager

j. Issue Morale and Welfare (MWR) membership card for OSD Welfare and Recreation Association

(civilian and military only)

k. Provide information on Pentagon Library

l. Provide information on Pentagon Athletic Center

m. Obtain copy of Military Orders if applicable

2. EMERGENCY PLANNING (COOP ADMINISTRATOR)

Room No.:

a. Escape Mask Equipment and Training

b. Provide organization evacuation procedures and egress route map

c. Add employee to Emergency Notification System (NOTIFIND)

d. Issue Government Emergency Telephone System (GETS) card

e. Update organizational COOP roster

f. Add employee information to DFD Emergency Preparedness List

g. Special badging requirements for COOP deployers

h. Provide copy of union-management agreement if applicable

3. MILITARY PERSONNEL

Pentagon, Room 5E565

a. Military member check in with WHS/Military Personnel Services

b. Provide copy of orders to organizational component

4. PHYSICAL SECURITY

Room No.:

a. Provide Federal Employee Compensation Act (FECA) physical security reporting information

(e.g., hazards, accidents, injuries, illnesses)

b. Provide information on safety training, medical, personal protective equipment

c. Provide ergonomic information and assessment of workstation for identifying accessibility needs

if applicable

SD FORM 819, FEB 2009

Page 2 of 3 Pages

ACTION ITEM

INITIAL/DATE COMPLETED

5. SECURITY MANAGER

Room No.:

a. Identification Cards

(1) Common Access Card (CAC) - fingerprint requirement, NACI

(2) NCR/Contractor Badge

b. Security notification for DoD civilians and military

c. Security notification for contractors (Visit Authorization Request (VAR))

d. Completion and signature on Standard Form 312

e. Attestation completed

f.

Component Security Briefings as required

g. Courier Card (if needed)

h. Security Access (Swipe Access/SIRP Access/Lan Room/PIC Numbers)

6. INFORMATION TECHNOLOGY

Room No.:

a. Signed DD Form 2875, "System Authorization Access Request (SAAR)", to create account

(e.g., local and global email accounts)

b. Request for IT Equipment, COOP IT Equipment (e.g., laptop, BlackBerry, cellular phone,

if needed)

c. Domain Manager Identification

d. Contact WHS Enterprise Service Desk - (703) 693-9842 for information, if needed

e. Read and sign "Consent to Monitor" Statement

f. Create Remedy Account, if needed

g. IA Certification (X one)

User

System Administrator

h. Establish global email account

7. SUPERVISOR

Room No.:

a. Notify timekeeper and/or add account authorization for ATAAPS

b. Identify system access needed and take appropriate action to initiate required paperwork

c. Office space secure lock combinations (e.g., cipher lock/XO-9, etc.)

d. IDS alarm access established; PIC/PIN provided to employee if applicable

e. Address NSPS responsibilities (performance plan, appropriate training)

f. Identify development and training plan as appropriate

g. Schedule orientation and mandatory/recommended training

h. Brief employee on MyBiz and MyPay accounts

i. Office of General Counsel (OGC) Standards of Conduct (OGE Form 450 within 30 days), if

applicable

j. Schedule in Brief with Organization Director if applicable

SECTION 8 - CERTIFICATIONS

1.a. EMPLOYEE SIGNATURE

b. DATE SIGNED (YYYYMMDD)

2.a. ADMINISTRATIVE OFFICER SIGNATURE

b. DATE SIGNED (YYYYMMDD)

3.a. SECURITY MANAGER SIGNATURE

b. DATE SIGNED (YYYYMMDD)